Healthcare Provider Details

I. General information

NPI: 1326701020
Provider Name (Legal Business Name): DUSTIN BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 MAIN ST
THOMPSON FALLS MT
59873-9355
US

IV. Provider business mailing address

PO BOX 609
PLAINS MT
59859-0609
US

V. Phone/Fax

Practice location:
  • Phone: 406-827-4349
  • Fax:
Mailing address:
  • Phone: 406-826-3552
  • Fax: 406-826-3599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHA-PHA-LIC-79739
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: